BSA New Patient Form: HIPPA

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* 1. Name

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* 2. Date of Birth

Date

Date

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* 3. HIPPA

BSA Physicians Group Inc. complies with HIPAA regulations; therefore we require that you complete the following section. Please understand that we can only share information with the person(s) and/or organization(s) that you list. Any person(s) and /or organization(s) that are not listed can only receive information after the patient or patient's responsible party has signed a release of information form. The list below will be considered valid unless a written request is received by the patient or the responsible party revoking consent.

Accept

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* 4. Section 4 - MR#

Person 1

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* 5. Name:

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* 6. Date of Birth:

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* 7. Phone Number:

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* 8. Will this person be bringing the patient to their appointments?

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* 9. Address:

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* 10. Relationship:

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* 11. Work Number:

Person 2

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* 12. Name:

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* 13. Date of Birth:

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* 14. Phone Number:

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* 15. Will this person be bringing the patient to their appointments?

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* 16. Address:

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* 17. Relationship:

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* 18. Work Number:

Person 3

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* 19. Name:

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* 20. Date of Birth:

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* 21. Phone Number:

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* 22. Will this person be bringing the patient to their appointments?

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* 23. Address:

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* 24. Relationship:

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* 25. Work Number:

Person 4

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* 26. Name:

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* 27. Date of Birth:

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* 28. Phone Number:

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* 29. Will this person be bringing the patient to their appointments?

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* 30. Address:

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* 31. Relationship:

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* 32. Work Number:

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* 33. Date

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* 34. Responsible Party